UNICEF/WHO/FFI Meeting on Implementation in Asia of the Recommendations on Wheat Flour Fortification

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Summary

Vitamin and mineral deficiencies affect not only the overall health of individuals, but also learning abilities, productivity, and overall social and economic development, therefore, constraining progress towards the achievement of the Millennium Development Goals. Food fortification in general, and flour fortification in particular, is one among several strategies that form a comprehensive and holistic approach to enhance nutrition and health by improving micronutrient status. Flour fortification has been implemented successfully and sustainably in several countries for more than 60 years; however, national standards for what micronutrients to add, which compounds are most effective, and how much to add vary widely. In April 2008, the Flour Fortification Initiative (FFI) and United States Centers for Disease Control and Prevention (CDC) organized an international meeting of nearly 100 leading nutrition, pharmaceutical and cereal scientists and milling experts from the public and private sectors to develop practical recommendations for flour fortification. Based on these findings, the World Health Organization (WHO), United Nations Food and Agriculture Organization (FAO), United Nations Children's Fund (UNICEF), Global Alliance for Improved Nutrition (GAIN), Micronutrient Initiative (MI) and Flour Fortification Initiative (FFI) released an interim consensus statement on the recommendations of the wheat and maize flour fortification meeting report. These recommendations are commonly known as the WHO Recommendations on Wheat and Maize Flour Fortification.

To capitalize on this new opportunity, WHO, UNICEF and FFI organized a regional meeting to disseminate the global recommendations among key stakeholders, clarify issues and support the implementation of these recommendations in the context of existing and planned flour fortification programmes in Asian countries. Eight countries were invited to attend the meeting, namely: China, India, Indonesia, Malaysia, Mongolia, the Philippines, Sri Lanka and Viet Nam. These countries have ongoing mandatory flour fortification programmes or have expressed an interest in establishing national programmes.

The objectives of the meeting were:

(1) to inform policy-makers and millers about the new recommendations on wheat flour fortification and of the implications of these recommendations on premix costs, flour product properties and trade;

(2) to outline steps for national adoption of the recommendations, in developing or revising national flour fortification programmes; and

(3) to identify national and regional approaches to improve the effectiveness of national fortification programmes.

The WHO recommendations clarify and inform decisions about what compounds are most effective and about appropriate levels to achieve significant public health impact. While the recommendations are global, they recognize that fortification standards “should be viewed in the context of each country’s situation.” A major criterion for selection of fortificant compound as well as level of fortification is “the usual consumption profile of fortifiable flour (i.e. the total estimated amount of flour milled by industrial roller mills, produced domestically or imported, which could, in principle, be fortified).” In addition, the WHO recommendations stress that beyond developing a fortification profile appropriate to consumption levels, effective programmes “should include appropriate Quality Assurance and Quality Control (QA/QC) programs at mills as well as regulatory and public health monitoring of the nutrient content of fortified foods and assessment of the nutritional/health impacts of the fortification strategies.

A review of the background and supporting evidence for each of the five key micronutrients included in the WHO recommendations was present to this regional meeting by international experts. The meeting then considered the implications of adopting the WHO recommendations. A report was presented on a series of studies undertaken in China, India, Indonesia, Malaysia, the Philippines, and Sri Lanka to see if Asian food products could be made with flour fortified as per the WHO recommendations. The study showed that the fortified foods had acceptable sensory properties and were similar to those made with non‑fortified flour. Attending premix suppliers led a panel discussion to elaborate and answer outstanding questions on financing and supply issues resulting from the WHO recommendations. The industry representatives felt that the compounds and levels recommended by WHO would have no negative interaction among nutrients – either in the premix or in the flour products – and would not impact the logistics and supply of premix. In some cases, the recommended levels and compounds may marginally increase the current cost of flour fortification. Overall, millers from throughout the region stressed their support of flour fortification and the new WHO recommendations.

The meeting then discussed how to apply the recommendations in the attending countries, including considerations for writing national standards and how to calculate flour consumption and potential impacts of flour fortification. The WHO recommendations prescribe that, as the amount of flour consumed by a population increases, the amount of nutrients added decrease proportionately, to avoid excessive consumption of some micronutrients. Calculations undertaken in the meeting concluded that flour fortified with ferrous salts (sulphate or fumarate) at WHO-recommended levels would provide one to two thirds of WHO estimated average requirements (EAR) for iron (with consumption of 75–450 grams per day), and flour fortified with vitamin A and folic acid would provide approximately 30% to 100% of WHO EAR (with consumption of 25–450 grams per day). Principles of quality assurance and methods of monitoring and evaluating the process and impact of flour fortification were also discussed. It was recognized that data on the impact of large-scale fortification programmes are lacking and significantly more effort is needed to monitor and evaluate national programmes.

In the concluding session of the meeting, country teams undertook a rough assessment of flour consumption levels, using available data, and calculated the potential impact of flour fortification on nutrient intake if the WHO recommendations were adopted. They then discussed potential fortification levels and how existing standards might need to be changed. Cost implications of these changes were also calculated. Overall, all countries felt that adoption of the WHO recommendations would be possible and advantageous. The meeting also re-affirmed the importance of strong private and public sector collaboration if flour fortification is to be implemented successfully. Private sector partners at the meeting demonstrated their commitment to flour fortification and their wish to engage in stakeholder collaboration.